Textbook symptoms of plantar fasciitis. (The Clinic).

? I am nearly 50 and have been running for about 22 years at 8:00-minute pace averaging 15 miles a week. I am generally in good health and have not had any serious injuries. Over the past few months I have been experiencing significant pain in my heel when I step on it, especially after first getting up from lying or sitting down. It forces me to walk with a limp. I don't notice it when I'm running. On occasion I also have pain when I step down on my toes, or just below them. Does this have a name? What do you recommend?

Daniel Moss, Englewood, NJ

You have classically described plantar fasciitis. This is inflammation of the ligament that runs from the base of your toes to the bottom of your heel. It helps to support your arch.

Over the years, this ligament is subject to stretching. When it stretches too much, it becomes inflamed. Running can create damage to the ligament similar to the way in which a rope begins to fray. At rest (such as sitting and sleeping), the ligament tightens, trying to repair itself. When you again stand or walk, you feel pain as the ligament first stretches or is reinjured. As you continue to walk, this initial pain usually subsides because you are stretching the ligament. The stretch-and-repair cycle goes on and on if left untreated.

First of all, stop running and let the ligament heal. Non-impact sports like swimming and biking are a good way to continue to exercise during this period, which will take six to 12 weeks (possibly longer). Arch supports or quality orthotics like those made by Spenco can help. Stretch your calf muscles to help decrease the pull on the heel. You may need to be fit for a night splint. Occasionally physical therapy and anti-inflammatory medicine may be necessary.

Gene S. Mirkin, DPM, Kensington, MD

In addition to calf stretches, rolling your foot over a frozen water bottle and avoiding going barefoot may help.

Amol Saxena, DPM, Palo Alto, CA

With appropriate physical therapy, my patients rarely cease running altogether. The running needs modification, to be sure. I may have them stretch, then walk for 10 minutes to gently elongate the plantar fascia before even attempting a jog. Icing afterward is a good idea.

Bruce Wilk, PT, OCS, Miami, FL

Since the symptoms are unilateral check for a functional leg length difference as a result of a lumbo-pelvic dysfunction (see Hamstring Woes, Jan/Feb Clinic). Always consider a calcaneal stress fracture or tumor. Bone scanning and MRI may be useful. Older runners get thinning of the plantar heel fat pad or plantar periostitis of the calcaneus. On occasion posterior tibial tendinitis or tarsal tunnel syndrome may be the cause of the symptoms.

Mitch Goldflies, MD, Chicago, IL

As with most overuse injuries, a combination of stretching and strengthening is the key. To stretch the plantar fascia, place your toes against a wall with your heel on the ground. As you ease down on the ligament. you will feel it stretch. Steriod injection at the pain site may also help. If you use a night splint, make sure it has an elastic stretcher. For shoe supports, I like Tuli's heel cups with a waffle sole.

Marvin Bloom, MD, Burlingame, CA

See Ben Pearl's review of ESWT on page 5 for an additional treatment option.

Jeff Venables, Editor